Rethinking Condom Use in HIV Prevention

In 1993, the year Carl Milner graduated from Drexel University College of Medicine, AIDS-related complications killed some 33,000 people in the U.S. One of them was Milner’s medical-school roommate.

About a year ago, Milner, now a physician and chief medical officer for the nonprofit AIDS Healthcare Foundation, was seeing patients at the foundation’s clinic in Oakland, Calif., when two men — young guys, both in their 20s, one Black, the other Latino — came in. Both tested positive for HIV. 

Milner treated patients living with HIV in prison, preaches the gospel of safer sex, and mans the clinic in part to honor the memory of his med-school roommate, forced himself to check his frustration.

“It's kind of hard to beat someone up at that point,” he said. “People in this new generation, they never saw the face of AIDS. That ‘wasting’ look — that was fearful. I think that that made folks want to put on a condom.”

That fear, Milner and others say, is largely absent from the lives of younger Black gay men. And, experts say, so is the use of a condom. 

Shifting Attitudes and the Condom Decline

Studies show condom usage, a low-cost, highly effective way to prevent HIV and sexually transmitted infections, has plunged among Black men over the last few decades, even as the number of both HIV diagnoses and STI cases has steadily ticked up. 

The reasons for the rise in condomless sex, experts say, are complex, ranging from the public health community’s focus on getting people to take PrEP, to incidences of personal trauma to the sheer pleasure of condomless anal sex. 

But that lack of anxiety to use a condom, coupled with lower rates of PrEP use and ongoing increases in HIV diagnoses in the Black community, has experts predicting a boom of new HIV diagnoses in future generations.

In the 1990s, as the AIDS crisis swept in NBA superstar Magic Johnson and pioneering rapper Eazy E., condomless anal sex was framed as dangerous and possibly lethal if you weren’t careful. Doctors, scientists and public-health professionals put the word out: abstinence or use of a condom is the only way to prevent HIV transmission. 

“But that lack of anxiety to use a condom, coupled with lower rates of PrEP use and ongoing increases in HIV diagnoses in the Black community, has experts predicting a boom of new HIV diagnoses in future generations.”

Coupled with data on climbing HIV rates, grim stories, and deaths, the community got the message: condoms were the only option for staying alive. Sex without condoms became taboo; even raising the issue drew public scorn.

Then came medical breakthroughs like PrEP - pre-exposure prophylaxis, drugs which can prevent transmission of HIV - and the glove, so to speak, came off. A positive HIV test no longer meant a death sentence. Condom use gradually fell, and the nation’s overall HIV diagnosis rate fell significantly. 

One problem, though: PrEP didn’t have as big an impact on the Black community as it did among whites. In 2022, roughly 10 years after it hit the market, Black people accounted for just 13% of all PrEP users, but 42% of all new HIV diagnoses.

Experts say the reasons range from the personal - people associating using PrEP with the stigma of HIV - to the systemic. That includes racial disparities in access to healthcare and racial bias in the doctor’s office.

“The conversations [about PrEP] are not happening,” Milner says. “The [medical] guidelines are that anyone sexually active over age 15 should have an HIV test. But do you think a pediatrician is ordering this? Do you think primary care doctors are ordering it? They're not.” 

It’s a particularly acute problem for Black men.  

According to the Department of Health and Human Services Office of Minority Health, Black men, in 2022, were 7 times more likely to be diagnosed with HIV than white men. At the same time, Black men were 6 times more likely to die with HIV than white men. 

Those data points, though, fly in the face of what Milner sees and hears in his clinic. Young gay men believe they are invulnerable and will live forever, even if they are diagnosed.

“They think that they are Teflon and [HIV] won't affect them,” he says. Because of retroviral drugs and other medication, he says, “People won't die from HIV. They will live with it. And I think that message is loud and clear to young MSMs, and so it has affected condom use.”

Then there’s the pursuit of pleasure, and the rise of pornography. There’s not much current research or data on the subject, but a 2016 paper published in the American Journal of Community Psychology found that young Black gay men receive an array of conflicting messages when it comes to condom use. 

“People in this new generation, they never saw the face of AIDS. That ‘wasting’ look — that was fearful. I think that that made folks want to put on a condom.”

— Carl Milner

While some men interviewed for the paper reflected safe-sex messaging, others were influenced by myths about condoms (decreased pleasure), stereotypes about Black male sexuality (“Black men’s penises were too big for condoms”) and the “rush” of engaging in sexually transgressive behavior. 

Not using condoms “is in some ways for the young Black man more stimulating and gratifying,” one subject, a young Black man from Chicago, is quoted as saying in the paper. “It wasn’t portrayed as being unsafe, but rather a more gratifying experience … Mentally and sexually and for some reason, you know what I’m sayin’, it just triggers the behavior and the mental stimulation of taking a risk.”

Meeting the Challenge with Conversation and Change

For Milner, the key to reversing that behavior is increasing communication.

“We have to get the message out about condom use,” he says. “But this generation can't even have ‘condom fatigue’ because they're not old enough. You know, middle aged folks are taking off condoms as well, but partly because they've gotten condom fatigue.”

Getting that message to Black gay men, however, isn’t going to be easy, particularly with the return of President Donald Trump to the White House. Milner expects the new administration will continue its crackdown on the Centers for Disease Control and Prevention, LGBTQ issues and race as well as raising the hurdles for publicly-funded community education.

“You know, books are already banned in certain school districts,” he says. “So, yeah, that's going to just add to the difficulty that we have with getting that message out there. That's why we have to and I think our media department at AHF is doing the job of trying to get the message out on social media because that's what we have to meet people” where they are.